Whole Person Care Pilot – California’s 1115 Waiver Renewal, Medi-Cal 2020

Health systems across the nation serving the Medicaid population have recognized the dynamic interplay between an individual’s social needs and their health. Medicaid and uninsured patients have frequent unmet needs related to behavioral health, substance abuse, housing, access to food, unemployment and other core health-related social needs. Emerging research has shown that the lack of provision of such social services has an impact on an individual’s health care outcomes. For most patients in the U.S. health care system, navigating the maze of fragmented medical and social care has resulted in uncoordinated, duplicative services that have less than optimal impact on patient health.

The Centers for Medicare and Medicaid Services (CMS) has acknowledged the need for improving value in our existing healthcare system and is currently testing a broad portfolio of alternative payment models and pilot programs that seek to support the Triple Aim. With these goals in mind, on December 30, 2015 CMS approved California’s Section 1115 demonstration waiver renewal, titled “California Medi-Cal 2020 Demonstration (Medi-Cal 2020).  The renewal of the waiver allows California to build off successes of the initial waiver, A Bridge to Reform, and continue its work transforming service delivery to Medi-Cal’s 12.8 million members by improving quality, access and efficiency.

Medi-Cal 2020 has four major initiatives, all with the goal to improve the quality and value of care provided to California’s Medi-Cal beneficiaries. The four major initiatives include:

1. Public Hospital Redesign and Incentives in Medi-Cal (PRIME)
2. Global Payment Program
3. Whole Person Care Pilot
4. Dental Transformation Initiative

The following discussion will focus on the Whole Person Care Pilot and details around program design, stakeholders and implementation timeline.

Whole Person Care Pilots

The Whole Person Care (WPC) pilot is a five-year program aimed to provide more efficient, high quality, integrated care by better coordinating physical health, behavioral health and social services for Medi-Cal patients who are high users of multiple health care systems, yet continue to have poor health outcomes. The WPC pilots recognize the need to improve coordination of care across multiple systems to more efficiently address external factors that affect the health of individuals. The pilots seeks to convene strategic collaborations among stakeholders to foster synergies in infrastructure development and prevent duplication in program costs in order to address the unmet needs of patients from a systems perspective.

The pilot is funded through a combination of state and federal funds. Up to $300 million annually in federal funds is available to California for the WPC pilot. Total funding, including the local match, is not to exceed $3 billion over the five year program. Lead agencies are responsible for providing the non-federal share of the inter-governmental transfer (IGT). The WPC pilot payments will only support the following activities:

1. Providing payments for services otherwise not reimbursed by Medi-Cal, this includes housing services such as Individual Transition Housing Services and Individual Housing & Sustaining Services. In order for federal financial participation, local housing authorities and programs must be involved.  Payments in this category will only be made for patients who are Medi-Cal beneficiaries;
2. Building infrastructure for service integration, such as a Health Information Exchange (HIE); and
3. Implementation of strategies that support integration, reduce healthcare utilization, and improve health outcomes.

In order to apply, the pilots require a lead agency that must be either a county, city, health or hospital authority, designated public hospital, a district/municipal public hospital, or a consortium of the above entities. Participating entities must include one Medi-Cal managed care plan operating in the same geographic region as the pilot, local health services and specialty mental health agencies and at least two other community partners that have significant experience serving the target population. Each lead entity is responsible for identifying all participating partners.

Through integration of county agencies, health plans, providers and other stakeholders, the WPC pilots look to develop an infrastructure that will ensure sustainable collaboration across local entities. Infrastructure development may include the expansion of data management and sharing strategies among local entities that will support effective case management and patient monitoring across systems, and will provide for ongoing performance improvement. Pilots are also encouraged to explore strategies that enhance housing and support services for patients suffering from homelessness or are at risk of becoming homeless.

Pilot applicants had their first opportunity to show interest by submitting a Letter of Intent (LOI) on April 8th. Submitting an LOI is not required and does not prevent an entity from still applying. Final applications are due to DHCS on July 1 or 45 days after application release (whichever is later). Currently, the final application is expected to be released on May 16.

Interested providers and organizations serving high-risk Medi-Cal beneficiaries are encouraged to reach out to their local department of health services or public health regarding participation in a WPC pilot serving their geographic region.  The WPC pilot program and its associated funding provides an excellent opportunity for health systems and community organizations to align and develop a sustainable infrastructure to continue to serve high-risk populations in an integrated, coordinated fashion.

About COPE Health Solutions

COPE Health Solutions is a health care consulting firm that advises hospitals and health care systems on strategy, population health management, Medicaid waivers and workforce development solutions. COPE Health Solutions provides clients with the tools, services and advice they need to be leaders in the health care industry. For additional questions or recommendations on how get involved with your local WPC pilot, contact consulting@copehealthsolutions.com.